Nursing Assessment and Interventions Quiz

Nursing Assessment and Interventions: Various Conditions

• Hyperkalemia (High Potassium): Before administering Kayexalate (sodium polystyrene sulfonate), assess bowel sounds to evaluate bowel function.

• Pregnancy and Urinary Frequency: For a pregnant patient experiencing frequent urination, an appropriate nursing response is asking about pain during urination to assess for a potential UTI.

• Uric Acid Kidney Stones: To prevent recurrence, patients should avoid foods like sardines and liver.

• Excess Fluid Volume: In a patient with excess fluid volume, watch for hypertension (high blood pressure) as a key sign.

• Chronic Kidney Disease (CKD) and Hemoglobin: A low hemoglobin level (e.g., 8.0) in a CKD patient suggests decreased erythropoietin levels, leading to reduced hemoglobin production.

• Loop Diuretics: Potential adverse effects of loop diuretics include a weak or irregular pulse and poor muscle tone, which require close monitoring.

• Urinary Incontinence: Interventions for improving bladder control include teaching biofeedback for pelvic floor muscle training, adjusting fluid intake (especially before bed), and teaching Kegel exercises.

• Acute Kidney Injury (AKI) and Hypokalemia: IV insulin is prescribed in AKI with hypokalemia to shift potassium into cells, thus lowering blood potassium levels. IV glucose isn't used to prevent hypocalcemia.

• AKI (Oliguric Phase): Monitor for ECG (electrocardiogram) changes and pulmonary edema during the oliguric phase.

• Fluid Volume Deficit: Lactated Ringer's solution (LR) is a common fluid replacement for fluid volume deficit.

Chronic Kidney Disease and Hemodialysis

• CKD Diet: Hemodialysis patients are often allowed more protein in their diets as urea and creatinine are removed during dialysis.

• Diuretic Therapy and Potassium: A decreased potassium level (<3.5) during IV diuretic therapy warrants immediate physician notification.

• Calcium Carbonate (Caltrate): Monitor phosphate levels to track the effectiveness of calcium carbonate in patients with CKD.

• High Potassium Levels (AKI): For a patient with AKI and potassium level of 7.0, review medications for potassium content, place on cardiac monitoring, and notify the physician.

Sleep Apnea and Related Issues

• Sleep Apnea Assessment: A patient's bed partner may report frequent snoring as a sign of sleep apnea.

• CPAP Treatment: CPAP (continuous positive airway pressure) devices are used to treat sleep apnea.

• Post Tonsillectomy Vital Signs: A slightly slower heart rate (e.g., 56 bpm) after tonsillectomy, compared to previous readings is considered NORMAL. Continue to monitor vital signs.

• Sleep Disruptions: Exercise before bed may interfere with sleep.

• Sleep Deprivation Symptoms: Look for confusion and irritability as potential indicators of sleep deprivation.

• Sleep Apnea Management: Interventions include avoiding alcohol 3-4 hours before bed and referring obese patients to weight loss programs.

Postoperative Complications and Patient Care

• Deep Vein Thrombosis (DVT) Prevention: Remind patients of leg exercises, and consider sequential compression devices (SCDs) to reduce the risk of DVTs.

• Preoperative Communication: It's NOT appropriate to send a patient with questions to surgery without addressing those concerns.

• Pain Management: Administering fentanyl is NOT necessarily safe for a patient with a high pain score (9/10) due to the possibility of patient history, and needs for the patient's individual circumstance and current pain management plan.

• Smoking and Surgery: Advise patients to stop smoking before surgery.

• Preoperative Assessment: Report a sore throat and fever to the Surgeon before surgery.

• Bowel Output: Colostomy output is typically thick, paste-like, or formed; ileostomy output is liquid or watery.

• GI Bleeding: The FIRST priority for a patient who has vomited bright blood is to take the blood pressure and pulse.

Gastrointestinal Disorders

• Heartburn (GERD): Nexium reduces stomach acid production, treating gastroesophageal reflux disease (GERD).

• Chronic Gastric Conditions: Peptic ulcer disease (PUD) is a combination of factors leading to gastric erosion, including certain medications and H. pylori infection.

• Peritonitis: Initial interventions for peritonitis from a ruptured diverticulum involve administering Flagyl and antibiotics IV.

• GI Bleeding: In older adults with GI bleeding, watch for fluid volume deficit.

• GERD Management: elevate the head of the bed on blocks to manage GERD.

• Recurring Heartburn: The nurse should explain that Nexium decreases stomach acid production.

Musculoskeletal Issues

• Fractures:

  • A patient experiencing possible lower leg fracture, initially check the popliteal, dorsalis pedis, and posterior tibial pulses.

• Open Fracture Treatment: Monitor the patients' temperature closely as a potential sign of additional stress.

• Femur fracture: After a femur fracture, the first action for shortness of breath and tachypnea is oxygen at 2 L.

• Osteoporosis: Increasing calcium intake and weight-bearing exercises can slow bone calcium loss in osteopenia/osteoporosis patients.

• Pain Management: For patients experiencing unrelieved pain (even with morphine), notify the healthcare provider.

• Rhabdomyolysis: In an accident involving a vehicle on ramps, rhabdomyolysis is a significant concern.

Skin Conditions and Chronic Conditions

• Atopic Dermatitis (Eczema): Assess pruritus (itching) as a common symptom.

• Chronic conditions and smokers: Smoking reduces functional hemoglobin and affects wound healing.

Discharge and Teaching

• Fractured Humerus: Teach patients with Vicodin to drink plenty of fluids and eat high-fiber foods to prevent constipation.

• External Fixation: Emphasize daily check and cleaning of pin insertion sites for external fixation devices.

• Post-surgical Pain: If pain persists or is not alleviated with medication prescribed to manage pain, the healthcare provider should be notified.

• Osteoporosis Diet: Recommend a meal plan including oatmeal with skim milk, fruits, and yogurt for effective osteoporosis management.

General Information

• Colic and Gout: Decreased serum uric acid can indicate the effectiveness of colchicine in treating gout.

• Wound Healing and Smoking: Smoking negatively affects wound healing through reduced hemoglobin function.

• First Assessment: In emergencies (e.g., severe abdominal pain, vomiting), assess that patient first.

This quiz covers essential nursing assessments and interventions related to various medical conditions such as hyperkalemia, urinary frequency during pregnancy, and chronic kidney disease. Test your knowledge on appropriate nursing responses and patient care strategies. It is ideal for nursing students and professionals seeking to reinforce their understanding of patient management.